Nokea
The HCP writes the following admission orders for the client with possible appendicitis. Which order should the nurse question?
- A. Place on NPO (nothing per mouth) status.
- B. No analgesics until diagnosis is confirmed.
- C. Apply heat to abdomen to decrease pain.
- D. Start IV lactated Ringer’s at 125 mL/hr.
Correct Answer: C
Rationale: A. Clients are kept NPO in case surgery is needed. B. Analgesic medications are usually withheld until a definitive diagnosis is established to avoid masking critical symptom changes. C. The nurse should question applying heat to the abdomen when appendicitis is suspected. Heat is contraindicated because it increases circulation, which, in turn, could cause the appendix to rupture. D. Isotonic IV fluids are initiated to replace lost body fluid and prevent dehydration.
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The client who has had a hemorrhoidectomy wants to know why she cannot take a sitz bath immediately upon return from the operating room. The nurse's response is based on which of the following concepts?
- A. Heat can stimulate bowel movement too quickly after surgery.
- B. Clients are generally not awake enough for several hours to safely take sitz baths.
- C. Heat applied immediately postoperatively increases the possibility of hemorrhage.
- D. Sitting in water before the sutures are removed may cause infection.
Correct Answer: C
Rationale: Heat increases blood flow, raising the risk of hemorrhage immediately post-hemorrhoidectomy.
Which medication should the nurse expect the HCP to order to treat the client diagnosed with botulism secondary to eating contaminated canned goods?
- A. An antidiarrheal medication.
- B. An aminoglycoside antibiotic.
- C. An antitoxin medication.
- D. An ACE inhibitor medication.
Correct Answer: C
Rationale: Botulism is treated with antitoxin to neutralize the toxin and prevent further paralysis. Antidiarrheals, antibiotics, and ACE inhibitors are inappropriate for botulism.
The nurse is admitting a client with the diagnosis of appendicitis to the surgical unit. Which question is it essential to ask?
- A. When did you last eat?'
- B. Have you had surgery before?'
- C. Have you ever had this type of pain before?'
- D. What do you usually take to relieve your pain?'
Correct Answer: A
Rationale: Knowing when the client last ate is essential to minimize aspiration risk during anesthesia for anticipated appendicitis surgery.
The clinic nurse is caring for a client who is 67 inches tall and weighs 100 kg. The client complains of occasional pyrosis, which resolves with standing or with taking antacids. Which treatment should the nurse expect the HCP to order?
- A. Place the client on a weight loss program.
- B. Instruct the client to eat three (3) balanced meals.
- C. Tell the client to take an antiemetic before each meal.
- D. Discuss the importance of decreasing alcohol intake.
Correct Answer: A
Rationale: Pyrosis (heartburn) in an overweight client (BMI ~33) suggests GERD, and weight loss reduces abdominal pressure and reflux. Balanced meals, antiemetics, and alcohol reduction are less primary.
The nurse assesses a large amount of red drainage on the dressing of a client who is six (6) hours postoperative open cholecystectomy. Which intervention should the nurse implement?
- A. Measure the abdominal girth.
- B. Palpate the lower abdomen for a mass.
- C. Turn client onto side to assess for further drainage.
- D. Remove the dressing to determine the source.
Correct Answer: D
Rationale: Removing the dressing to assess the source of red drainage (e.g., bleeding or dehiscence) is critical for timely intervention. Other actions are secondary to identifying the cause.